Venezuelans with HIV follow Bolívar's example and cross the Andes, but to receive treatment in Peru

The country with the largest oil reserve in the hemisphere neglects its people with HIV-positive and lets them die. Since 2012, medicines are scarce and the pandemic is spreading unabated in Venezuela. That is why dozens of patients have embarked on a 4,000-kilometer epic journey in order to save their lives and reach for the promised land where they will find both employment and health.

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In September 2016, Antonio went back home one afternoon without the anti-allergy his wife needed. After walking long hours through empty pharmacies in San Fernando, capital of the state of Apure (southwest plains), one thing was clear to him: both had to leave the country.

The stress caused by the permanent shortage of food and medicines was undermining their defenses and their situation worsened because they both were HIV patients. It was of paramount importance that they resumed their treatment, but in a country running short of antiretrovirals and common pills to treat a simple flu or an infection, waiting was as harmful as the disease itself. Little did they know back then that their struggle to stay alive would take them a long way around three countries of South America to receive medical attention and to get the vital drugs to control the AIDS virus. Peru turned out to be the final destination.

Antonio and Pamela have lived in Lima with their young daughter for nine months. They settled in a rented room north of the Peruvian capital because this was the only country where they could find employment to meet their basic expenses. "We needed to resume our therapies, but above all, we needed peace of mind. That helped a lot to reduce our viral load", says Antonio, a man of medium height and slow gestures, in a civil organization located in Lima that monitors the supply of antiretrovirals.

This family is part of a wave of 7,000 Venezuelans who, so far this year, obtained permits for a temporary stay enabled by the Peruvian government, according to data from the National Superintendency of Migration. Although there are no official statistics on the specific number of people who came from Venezuela for health reasons, since November 2016, the NGO Anti-retroviral Medication Surveillance Group (GIVAR) has registered 20 cases of Venezuelans with HIV who migrated to Peru specifically with the aim of resuming their therapies to control this disease. "People keep contacting us per e-mail asking us to help them receive the medicines for free," explains Marlon Castillo, coordinator of this group located in the district of San Martín de Porres, north of Lima.

In fact, Peru is not the first country Venezuelans think of when they migrate for health-related issues. The reason for this is simple geography: to reach this country by land, it is necessary to cross Colombia and Ecuador first. That is why those who migrate for treatment seek help in the Ecuadorian cities of Quito and Guayaquil, after a tiresome journey by land that crosses Colombia from Cúcuta, in the Norte de Santander department, which borders Venezuela, and finally reaches the border with Ecuador.

In Ecuador, the procedures for foreign citizens to access health services and antiretroviral treatment free of charge are quick and simple: you just have to present an identification card and medical history, in addition to attending to some orientation talks. But the problem there was something else: "We did not find work in Ecuador and we ran out of money", says Pamela, who was a teacher in a public school in her country, but now works as a saleswoman in a clothing store located in downtown Lima. Her husband, who was also a public employee, got a job as an assistant in a flannel factory in the commercial center of Gamarra, in La Victoria district of the Peruvian capital.

Before settling in Peru, the couple received specialized treatment for a few weeks at the Infectious Disesases Hospital of Guayaquil, the main port city of Ecuador. In spite of this, the new migration policies enabled by the Government of president Pedro Pablo Kuczynski made Peru a more appealing alternative.

Until a few months ago, Venezuelans arriving in Peru were required to obtain a permit to stay as refugees, but in January 2017, the Peruvian government approved a temporary residence permit only for citizens of that country. The document, which has a validity of one year, allows Venezuelans to study, work and receive health treatment even if they lack of a health insurance. "This support is namely humanitarian, because of the current situation in Venezuela. It is a token of gratitude for what they did when Peruvians were going through a time of terrorism" says a spokesman for the National Superintendency of Migration.

Until 2016, 2,666 citizens with a foreigner identity card were registered in the Integral Health System (SIS), which allowed them to receive medical care as insured. The case of Venezuelan migrants is different because many of them still do not bear the card. "This case is being studied to see how we can incorporate them into insurance with a minimal contribution", says María Cecilia Lengua Hinojosa, doctor in charge of risk management and evaluation of SIS benefits.

Foreign HIV patients receive their medicines without having to pay for them, as antiretroviral treatment is universally accessible and free worldwide. However, those who lack of health insurance in Peru must pay a fee for the clinical check-ups that can be assessed in the social welfare services of hospitals.

All these advantages were listed in various groups created on Facebook by other Venezuelans to help them follow the route to Peru. The married couple Pamela and Antonio were convinced that this was an opportunity. They drove from the border town of Huaquillas, Ecuador, heading for Zarumilla, Peru, spent a few days in Tumbes, and then took an interprovincial bus that finally led them to Lima. "Starting from scratch was difficult, but we were very lucky. Now we receive treatment in San José del Callao hospital", says Pamela, a 36-year-old woman in a cheerful tone of voice and restless hands as she speaks.

From awe to tragedy

On the afternoon of May 3, there was an outage in Caracas and activist Jonathan Rodríguez, president of the StopVIH NGO, had no choice but to use his car battery to recharge his cell phone and continue the interview he gave to the authors of this report through a Whatsapp channel. "There are people who die every day because of the shortage of medicines and hospital supplies in Venezuela", he wrote in distress. "The government just gives them the cold shoulder", he added.

The generalized crisis of the country, in addition to an ongoing humanitarian emergency, brutally harasses the care system for HIV patients in Venezuela, once an admirable example of public health, even during the first stage of the self-proclaimed Bolivarian Revolution, when the country challenged global pharmaceutical cartels and freely distributed ARV drugs imported from India.

But that lasted the same as the oil boom. Since 2012, medicines have become scarce and now they are almost impossible to obtain. The virus spreads again very quickly, more than 200,000 carriers survive in the country, which is a rough estimation. The disease is once again claiming a great number of lives in Venezuela, going back to the early 80's, but with the aggravating circumstance of the medical supplies shortage in hospitals, which hampers the patients from having palliative care and dignity in their agony. A newspaper report from the Toronto Globe and Mail, published in mid June,  found in Venezuela a more dramatic situation than that faced by African countries in the worst moments of the pandemic at the end of the last century.

Rodríguez's organization has documented 66 severe episodes of shortages of 25 antiretrovirals since November 2009 so far. This situation has endangered the lives of more than 65,000 people with HIV who received the medicines from the State in order to survive. Many patients are at risk of developing drug-resistant strains of HIV if they do not receive a timely treatment or abandon it, making their prognosis worse.

"What is happening in Venezuela goes against all global efforts to control the pandemic. The lack of sustainable ARV treatment in a country may translate into grave consequences to the population: more weakened patients, more cases of newly-infected people and more deads. Now, with the migratory problem, there is also the risk of spreading drug-resistant strains of HIV outside Venezuelan borders, which will worsen the HIV situation in the world", says Jesús Aguais, director of the civil organization Aid for Aids, based in U.S.

In 2012, the Pan American Health Organization (PAHO) already warned that Venezuela was the country with the greatest supply shortage of antiretrovirals in Latin America, a situation that has become more acute in the last two years and now it is preventing the control of this disease. Available figures from UNAIDS show that HIV/AIDS-related deaths in this country have increased. "In 1997, they did not exceed a thousand; In 2015, reached 3,300 cases", says Michela Polesana, communications officer for the United Nations agency for the region. This is not the only problem: in Venezuela there are also 44,000 people infected with HIV who are unaware of their condition and an average of 5,600 new patients add up every year.

Despite this bleak landscape, the Venezuelan Ministry of Health did not speed up virus prevention actions and purchase medicines to treat infected patients. In 2014, the Government acknowledged that from the 30 HIV medicines on their purchase list, only 14 were covered. Even less guaranteed the provisions of other essential drugs, such as anticoagulants and scar therapy products.

At the beginning of 2017, the situation reached the limit: 90% of the high-cost medicines, mostly antiretrovirals and oncological drugs weren't supplied to the hospitals' pharmacies in Venezuela. Imports of drugs are hampered because the state does not have enough budget to cover them. According to data from the pharmaceutical sector in Venezuela, since 2014 the Ministry of Health has had a debt of 4,000 million dollars with supplier laboratories. In that same year, the President of the Venezuelan Pharmaceutical Federation (FFV), Freddy Ceballos, said that the regime would regain the trust of the sector if the 60% of the debt was liquidated. But there is no indication that this condition has been fulfilled.

Health authorities have purchased antiretrovirals through PAHO's Strategic Fund for Medicines in 2015 and 2016. However, Antonieta Caporale, one of the three ministers for health that has been in charge in the last six months, said last April that this year's acquisitions could not be made on time due to administrative issues. "We knew that the whole lot would cost about 12 million dollars and the government had not enough liquidity", claims Alberto Nieves, from the NGO Civic Action Against HIV (ACCSI) in an interview for this report.

Dangerous resistances

When Elvis Ortuño left Valencia, the capital of the state of Carabobo and the main center of light industry in Venezuela, he had to leave behind his family, his significant other and his final year of college in Education. It was March 2016, he had found out that antiretrovirals were not guaranteed for the next few months and he feared for his life. In that moment, Elvis was still trying to assimilate the news that he was infected with HIV which they gave him barely one month earlier, and viral load tests warned that his CD4 values (a type of cell that helps fight infection) were below normal. "If I stayed, I would have been in risk of generating resistance to the treatment and would be unable to fight the virus," explains the 35-year-old who now lives in the northern city of Trujillo.

"They got us off the bus and checked our luggage"

Like many of his fellow countrymen, Elvis Ortuño explored on the internet the migration alternatives he had and embarked on a ground trip to Guayaquil, Ecuador. The road trip was not easy. He had been warned that he would undergo continuous inspections of National Guard officers in La Caramuca's alcabala, in the state of Barinas -the birthplace of Commander Hugo Chávez and his family, who had given it three governors in a row-, before continuing the route to his destination. "They got us off the bus and checked our luggage. I could see that they took away two passengers who supposedly carried illegal merchandise, but the reports that the guards themselves are planting things in your luggage are constant", he narrates.

Elvis' problem began in the Colombian migratory post to reach the city of Cúcuta from San Antonio del Táchira, in Venezuela. There, the officers prevented him from continuing his journey. The only way to let him pass was to show an air ticket back to his country, as evidence that he would not stay in Colombia. For a day and a half he looked for alternatives to cross the border: he begged the police for hours and asked a doctor to provide him with a travel certificate for health reasons, but none of that worked. Only when he showed the reservation of the plane ticket that had been issued to him by an Ecuadorian travel agency that he contacted by telephone, his passport was sealed and crossed the border.

"I knew that as I passed the Simón Bolívar International Bridge my life was about to change"

"I knew that as I passed the Simón Bolívar International Bridge (Editor's Note: over the Táchira River, border between Venezuela and Colombia) my life was about to change. It was like a sign of hope", he says. At the time, Elvis Ortuño had just $120 in his pocket, his last antiretroviral kit that would cover his therapy for one month and a small suitcase with clothes. The next step was taking the bus from Colombia to Ecuador.

After 36 hours of travel, the thin brown-skinned young Venezuelan arrived at the International Bridge of Rumichaca, where he entered Ecuador. His exodus was due to end at the Infectology Hospital of Guayaquil, so he had to make more connections with interprovincial transportation services to cross Ecuadorian territory and fulfill his objective. In that health service he received the attention he was hoping for: he was given the antiretrovirals just by showing his medical history and he had no problem accessing the medical check-ups for free. A predicament arose when seven months later, he couldn't be able to find a job to sustain himself. He then researched a second destination option online and communicated by mail with the GIVAR group to help him receive antiretroviral treatment in Peru.

In October 2016, Elvis Ortuño crossed another border but this time he was confident that he would get treated better. He did not arrive to Lima, he stayed in the city of Trujillo instead, in northern Peru, where he was able to join the free antiretroviral treatment program at the Belén Hospital and he was employed as a waiter in a restaurant. Now he feels calm, because his clinical tests show that he has not become resistant to the medicines, even though he had to interrupt his therapy sometimes.

If a patient with HIV stops taking their medication when they are between the sixth and ninth month of therapy, their viral load will increase and the drug will stop working"

However, this anguish is experienced by thousands of infected countrymen that still remain in Venezuela. "If a patient with HIV stops taking their medication when they are between the sixth and ninth month of therapy, their viral load will increase and the drug will stop working. If there are many patients who are in this situation, obviously the epidemic will be out of control", explains Dr. Eduardo Sánchez Vergaray, president of the Peruvian Society of Infectious Diseases (SPEIT).

This year alone, five episodes of antiretroviral shortage have occurred in Venezuela: since January there is no Zidovudine in children's syrup and since February there are no reserves of Complera, a tablet containing rilpivirine, emtricitabine and tenofovir. The situation is so serious that this country no longer has reliable epidemiological data because there are no reagents for the clinical evaluations. "We do not know how we are", states Elia Sánchez, infectologist and former president of the Venezuelan Society of Epidemiology.

Dr. Sánchez says there is little possibility of correctly measuring the resistance levels of HIV patients because there are no medical supplies to undergo the tests. It has been three years since the last genotype test was done in this population and for six months there have been no reagents for viral load analysis that every patient should get done every three to four months.

HIV was one of the diseases to which the Venezuelan State dedicated the largest budget since the national program to control the epidemic was created in 1999. However, nowadays the Ministry of Health does not give priority to it. "The treatment regimens are composed of old medicines. The country does not have modern therapies because they are very expensive", claims Sánchez.

Retained Donations

In Venezuela, the State is the sole responsible for importing medicines to supply pharmacies and there are two non-governmental organizations that have a drug bank sustained by donations: Caritas Venezuela and the Coalition of Organizations for the Right to Health and Life (Codevida), through the program Minority Action of Venezuelans, which is supplied by donations sent by compatriots abroad. However, shipments are increasingly restricted and limited. Alberto Nieves, of the NGO Solidarity Action Against HIV, denounces that he has witnessed how the authorities have retained lots of medicines that have been brought from abroad and were not distributed to the beneficiaries.

The Government placed incomprehensible restrictions for the entry of these lots of medicines

In addition, in 2016, Caritas International tried to send 75,000 units of essential medicines, but authorities seized the cargo at the airport. According to spokespersons of this organization that were contacted for this report, the Government placed incomprehensible restrictions for the entry of these lots of medicines.

Although in Caracas part of the population of patients with HIV survives with the last reserves of medicines of the Ministry of Health, they do not arrive at urban centers of province like Valencia, Maracaibo and Barquisimeto, where cases of children and adults have been reported with more than four months without antiretroviral therapy. For this reason, more and more people like Antonio, Pamela and Elvis decide to make a long journey through Latin America to get the drugs and save their lives.

Health services in Colombia, the Dominican Republic and Panama have also reported groups of Venezuelans with HIV who have been admitted to their free antiretroviral therapy programs in the past two years. There are no data available on the specific number of migrants with this health condition, but the exodus of patients worries some NGOs in Venezuela because they fear that the health systems of other countries will see their budgets and medicines reserves affected. In the Dominican Republic, for example, the cost of care for foreign patients with HIV was estimated at $1.4 millions in 2016. The majority of those attended were Haitians and Venezuelans. "This situation would be avoided if the government recognized the serious public health problem that we have and accepted international humanitarian aid without complications", declares Alberto Nieves, of Solidarity Action Against HIV.

In May, the widespread shortage of medicines triggered a massive march of patients and health professionals in Caracas, who resisted the tear gas and the National Guard crackdown that tried unsuccessfully to prevent them from reaching the Ministry of Health. The sick people who took to the streets had a motto: "If we do not go out, we still die because of the lack of medicines".

(*) Report prepared especially for Armando.info by the website Ojo Público, of Lima, Peru, within the framework of The Big Pharma Project.

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